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Hello all
I'd like to get your opinion on a case that arose this morning in my clinic.
Patient 21 years old, military, suffered 2 months ago from a inversion grade I ankle sprain on is right foot, he whas treatmented whid ice and took anti-inflammatory drugs during the first 24 hours after that the orthopedic immobilized the foot using plaster for about 1 month.
After this month he was discharged because he had no painful symptoms.
When he returned to is training after 3 weeks he started feeling pain on the outside of the foot that incapacitated to carry out is activities.
The patient brought all the exams he had done at the time of the sprain (Rx, and MRI).
During my initial evaluation I dint come across any signs of bruising, swelling or edema, however, performing inversion of the foot the patient complained of a very painful pain along the peroneal tendon and muscle activity of this muscle is practically non-existent because of the pain. In assessing the rearfot in prone position I found it to be in about 4 ° varus position and to assessing the rearfoot in heightbaring he had a valgus reafoot of about 2º.
My initial suspicions were that this is a peroneal tendinitis or perhaps a Sinus tarsi syndrome?
My inicial treatment plan is to perform a orthotic device whid a valgus extension to Increases pronatory torque under the metatarsal heads in order to reduce supinatory torque.
I would like to hear your opinion on this.
Hi Andre
Has the patient had any physiotherapy? Any type of rehabilitation?
Trigger points through the peroneal muscles can give such pain and dysfunction.
1 month in a cast seems unusual and I would expect functional rehabilitation would be essential.
Cheers
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
1 month in a cast seems unusual and I would expect functional rehabilitation would be essential.
Cheers
Agreed. You can, of course, have both problems with peroneal muscles and sinus tarsi syndrome post inversion sprain. You should work on your diagnostic techniques and anatomy if you don't know how to differentiate between these structures.
__________________ Science is the antidote to the poison of enthusiasm and superstition
and some articles on other things to look for in peroneal problems.
Ihave some other articles on the work computer that I can upload on Monday.
I would suggest as the others have said that you need to work out where the pain is comming from before you start tx. Maybe consider a MRI or Ultrasound to get a full diangnostic picture. Look at the cuboid as well it maybe subluxed (an paper on that on Monday for you) .
Quote:
My inicial treatment plan is to perform a orthotic device whid a valgus extension to Increases pronatory torque under the metatarsal heads in order to reduce supinatory torque
If it is peroneal related ( brevis,longus) consider a RF Lat Skive as well as the Valgus extension.
But you maybe need to consider other tx options as well as the orthotic, ice, rest physio ( as others have said), but I would suggest some more investigations with MRI/ultrasound to get a exact diagnosis then you can build a better tx plan.
__________________
Michael Weber
The most common thing about common sense is it´s not very common.
think cuboid syndrome, look at 5th ray r.o.m. If reduced, manipulate.
how is stj rom, end range of eversion sticky? calc-cuboid joint restricted?
check for myofascial trigger points in peroneals.
casted for 1 month? will probably need home strengthening program i would think
orthoses- semi rigid poly shell, ext rearfoot post 0/0, 4 degree forefoot valgus posting, no lat arch fill, max medial longitudinal arch dressing reinforce/fill plantar lat longitudinal arch.
good luck
scott
The Following User Says Thank You to footdoctor For This Useful Post:
My initial suspicions were that this is a peroneal tendinitis or perhaps a Sinus tarsi syndrome?
My inicial treatment plan is to perform a orthotic device whid a valgus extension to Increases pronatory torque under the metatarsal heads in order to reduce supinatory torque. I would like to hear your opinion on this.
If it's sinus tarsi compression then you need to increase external supination moments. If it's stress in the peroneals then you need to decide which peroneal and why it is excessively stressed.
E.G. the peroneus longus might be stressed by resisting supination of the STJ or it might be stressed by resisting the 1st ray being dorsiflexed. The latter may happen because the 1st ray/MPJ is low or stj pronation increases GRF at the 1st MPJ and in both cases 1st ray dorsiflexion is compliant to GRF.
It is essential that you identify the injured tissue and the reason why in terms of increased stress.
ANdre:
I think you should redo his history, something is amiss here.
If he had a grade 1 sprain why order an MRI and why cast him for a month? This sounds as though the initial injury was more severe. The mechanism and severity may help you evaluate this patient more correctly.
FYI: around 50% of linear peroneal tears are missed on an MRI.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Peroneal Tendinitis or Sinus Tarsi Syndrome?
Re: Peroneal Tendinitis or Sinus Tarsi Syndrome?
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